improvement in behavioral healthcare; however, it is not a sufficient condition. As noted previously, significant progress has been made in measure development in recent years. Major developers, such as the National Committee on Quality Assurance’s Health Employer Data and Information Set (HEDIS) and state mental health and substance abuse agencies, have adopted performance measures in both mental health and substance abuse treatment; however, it is how the various stakeholders in behavioral health use these types of measures that ultimately drives quality improvement.
Evidence to date shows ample room for improvement with relatively low rates and scores on many measures. In fact, recent reporting on HEDIS behavioral health measures shows that the measures have been relatively flat over the last few years, unlike many of the medical measures that have shown significant improvement (NCQA, 2004b). Between 1999 and 2002, the five behavioral health measures in HEDIS only had a 2 percentage point increase overall (48 percent to 50 percent) and the two lowest measures actually declined 0.5 percentage points. Whereas during the same time period, the non-behavioral health measures in HEDIS increased 10 percentage points overall (57 percent to 67 percent). The five lowest measures increased 18 percentage points and the five highest measures were up 6 percentage points indicating substantial improvement for the non-behavioral health measures (Goplerud, 2004).
We are at a critical juncture for behavioral health where a foundation has been developed in performance measurement, but stakeholders, including purchasers, health plans, provider groups, individual clinicians, patients, and researchers need to engage in the process of effectively using the measures to drive quality improvement (Horgan et al., 2003; Pincus et al., 2004). Adoption of performance measures involves multiple stakeholders with cross-cutting issues for all. In making this commitment to quality improvement in behavioral health, it is important to be
of use of performance measures. For example, multiple measures of the same concept by different developers may exist. Indeed, the plethora of similar measures and the lack of
standardization is a major challenge for both health and behavioral health performance measures. Coordination of the considerable activity in this area, an essential next step, is the explicit goal of the Forum on Performance Measures in Behavioral Health and Related Service Systems (Bartlett 2004). This goal is consistent with the aims of the National Quality Forum, which is focused on accomplishing these objectives more broadly throughout the entire health care system (National Quality Forum).
There also may be confusion about the relationship between process and outcome measures and when each is appropriate and sufficient. Recognition that patients with mental and addictive disorders may be difficult and expensive to treat and that they often have needs outside the health care system presents additional challenges. Solutions require collaboration across multiple stakeholders.
Purchasers
Purchasers may lack confidence in the business case for paying for services for mental and addictive disorders. However, they can use performance measures to ensure that what they are paying for is of high quality. Both public and private purchasers have many levers at their disposal to drive quality improvement. They can use performance measures in purchasing
decisions, seeking health plans and MBHOs that have better scores on measures. They can select a benefit design that reflects a chronic care approach and incorporates performance measures that cut across the full continuum of care, including maintenance. They can use performance
measures in contracts and work with plans to improve scores over time. In particular,
performance measures can be linked with financial and non-financial incentives and penalties. Purchasers’ “pay for performance” initiatives, which directly reward providers, are beginning to be used in the broader medical area, and have potential for the behavioral health area (Bachman, 2004).
Health Plans
Health plans have legitimate qualms about employing performance measures. The model type (e.g. group/staff HMO or network plan) implies different levels of plan control, and impacts the
plan’s ability to influence provider behavior. There are also concerns about both the expense of collecting the performance measures and the expense associated with implementing quality improvement initiatives. In a highly competitive health care marketplace, demand for performance measures from other stakeholders is important to justify the expense.
Health plans and MBHOs have several options for using performance measures. They can use and improve their data monitoring capacity to provide feedback to individual clinicians on their comparative performance on measures. This might be linked with provider incentive programs. They can design programs for quality improvement that could have a direct link to improving measures, e.g. screening protocols that might lead to higher rates of identification of mental and addictive disorders. MBHOs and health plans can improve their capacity to link across data systems.
Clinicians/Provider Group
Major barriers to performance measurement at the practice level relates to inadequate technology for data collection. This varies tremendously depending on setting with providers in some settings, lacking computer capacity. For example, as recently as 2003, 10.5 percent of specialty substance abuse treatment facilities did not have internet access (SAMHSA, 2004c). In addition, small numbers of patients with a particular diagnosis in a provider group setting may make it difficult to calculate stable performance measures.
The practice setting does offer opportunities to creatively engage in activities that can contribute to improvement in performance measures. Clinicians can follow clinical practice guidelines and otherwise hone their skills in treating patients with mental and addictive disorders. Recognition programs can be developed that use performance measure to honor clinicians who are delivering services of particularly high quality. Individual clinicians can participate in quality improvement initiatives in the practice setting.
Consumers/Patient
With the growing acknowledgement of the importance of patient-centered care (New Freedom Commission on Mental Health, 2003), the role of the consumer is important in using performance measures to drive quality. The mental health area has a long and well-established consumer movement; however, there is a much less mature constituency of consumers and family members
to advocate publicly for improved access and outcomes for persons with substance use disorders. There is also little evidence to date, that consumers use published performance measures in their decision-making. However, consumers can use consumer-oriented tools based on performance measures, e.g. NCQA’s Quality Compass, to be better become better informed about their health plan. They can participate in community coalitions and collaborate with patient advocacy groups to encourage the use of performance measures for accountability purposes.
Researchers and Developers
The development of performance measures in behavioral health has made great strides in recent years; however, improvement in measures is a continuous process and relies on both the ongoing development of evidence about treatment effectiveness and monitoring of improvements in data quality. Researchers can play key roles in three areas. First, researchers should continue to develop and test new measures, particularly as they relate the incorporation of the chronic care model into treatment practices. Secondly, researchers also can contribute to a better understanding of the links among performance measures, quality of care, and improved clinical and functional outcomes, the ultimate goal of treatment. Third, because the implementation of performance measures is challenging, researchers can contribute by studying the organizational and system factors that result in the effective use of performance measures.